Internal Medicine Coding Alert

Published on Thu Aug 16, 2012 PDF

Question: Our physician saw a patient for a non-displaced tarsal bone fracture, which did not require manipulation. He placed a prefabricated short leg, removable cast instead of applying a full cast. Documentation states that the patient shouldn't need additional treatment, but our physician recommended that she see an orthopedist in 2 weeks. Should we consider this encounter a type of fracture care?

New York Subscriber

Answer: Your physician determined that there is a fracture and decided on the appropriate course of treatment, so he met the requirements for reporting the fracture care code. Submit  28450 (Treatment of tarsal bone fracture [except talus and calcaneus]; without manipulation, each).

Note: Because your physician won't be providing the associated follow-up fracture care included in the global surgical package, append modifier 54 (Surgical care only) to indicate you are reporting only the procedure.